Provider Demographics
NPI:1326790726
Name:DIAMOND, KELLY (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DIAMOND
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 FAIRHILL RD
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:PA
Mailing Address - Zip Code:19070-1006
Mailing Address - Country:US
Mailing Address - Phone:610-945-8414
Mailing Address - Fax:
Practice Address - Street 1:300 OLD FORGE LN STE 302
Practice Address - Street 2:
Practice Address - City:KENNETT SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19348-1932
Practice Address - Country:US
Practice Address - Phone:484-778-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA005997363A00000X
PAMA063356363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant